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Case Study: Anger outbursts, difficulties with social engagement

🕑 6 minutes read
Posted June 26, 2018

CLIENT BACKGROUND: 4-year old male that presents as happy and ready to participate.

PRESENTING PROBLEM: His parents’ concerns are that he has emotional outbursts that are quite different from his normal personality.  The outbursts happen fast and sometimes he states very strange comments that do not seem to match his usual personality like, “I want to kill Santa Claus.”  During these outbursts they report that it is difficult to talk with him and connect.

Looking at the facial features of this young boy one notices that his eyes and eye area are not fully activated and engaged.  There is a flatness to this area and a reluctance to actually engage in directly looking at another. This could be a result of a compromise in the ventral vagal system.

INTERVENTIONS USED: The Safe and Sound Protocol was implemented for consecutive 5 days.

Session 1:

Client is engaged and ready to try out this new experiment. Coloring books, water colors, paper, stuffed animals, etc. along with pillows and a blanket have been provided for comfort and to keep him entertained while listening. It is explained that he will be listening to music, that the sound may go up and down and may even sound different than he is used to but all of that is part of the experiment. He is to just paint, draw, color and really listen to the music.  He is also instructed that he is to just listen to the music not try to sing along or dance. Therapist knows that client likes to sing and dance to music. Headphones are put on. He listens and then starts singing. Therapist smiles at him and puts a finger over her mouth. He smiles and stops. A few minutes later he starts dancing to the music. Therapist gets his attention, smiles and shakes her head no. He says why not? Therapist says it will confuse experiment, it is about listening. He says OK.  A few more minutes go by and he starts to fidget and asks, “how much longer”. A few more minutes and he says he is tired. He is encouraged by therapist to keep going. Part A is completed, and therapist asks if he needs a short break. He states he is very tired and does not want to do any more now. Therapist tries to encourage him to go on, but he is pretty insistent about stopping. He says that his ears are tired and that they have a funny sound in them. Therapist decides that it is better to give him space and will start with Part B the next day.

Session 2:

Client comes to session happy and ready to do the experiment. Environment is same as before with art supplies and comfy pillows, blankets etc.  Therapist repeats instructions about singing and dancing and client smiles and says, “OK, I get it”. Headphones are put on; he listens and paints.  Every once in a while, he starts to sing along but stops when therapist smiles and puts her finger over her mouth. They both laugh, and he goes back to listening.  At the end of Part B from Day 1, he says he is tired and would like to stop. Therapist gives him a break but encourages him to do Part A from day 2. He becomes very fidgety and is not really happy during this section. He keeps asking how much longer. They get to the end Day 2 Part A, but therapist realizes that he cannot complete the second part (B) and catch up, it would be too much.  Client states music is only a little strange that day. His ears feel a little funny but not as funny as yesterday.

Note: His sister comes with him on this day says she wants to do the experiment also.  She does Day 1 Part A and B after her brother.

Session 3:

Client comes and says he is ready. Normal set up. He is more relaxed during session.  Goes through Part B from day 2 and Part A from day 3. Towards end of part A, it is evident he is very tired again and losing interest in participating. He says he just needs to go outside and play.  Therapist decides to allow this as she does not want to push the issue and create negativity.

Session 4:

Client is more relaxed.  He goes through Day 3 Part B very well.  He says he can go right into next session. Therapist is hopeful that they will be able to get him caught up and do three sessions today but the last 5-10 mins of the second session he starts to fall asleep. Therapist holds his hands, smiles at him, does a little movement every time he starts to fall asleep and he makes it to the end, but it is clear that trying to do another session would not be good.

Session 5:

He asks if he can do it with his sister; sister also makes same request. Therapist does have an audio splitter and two headphones, so it is coordinated so that they both can do Day 4 Part B together by starting sister out first.  When they do Part B together, therapist makes sure they have separate “work areas” different blankets, art supplies but are just in same room. Therapist tells them it is important that they stay tuned to the music and not be engaged with each other or it may disrupt the experiment.  They say they understand. They do a good job of being focused on their projects but there is a nice smiling at each other every once in a while,

Day 5 Part A proceeds without sister.  Client becomes very tired, starts falling asleep about half way through.  Therapist does what she can to keep gently keeping him awake, he makes it to the end.  He is so relaxed, and it is evident he will not be able to complete another session. It is midafternoon and there is not time to give an hour break and come back to it as family has things to do that evening.  Therapist decides that only thing to do would be for him to do the last session the next day or to stop there. Therapist decides to do a half hour session the next day.

Session 6

Therapist has concerns as this is only supposed to be a five-day intervention, but client says he really wants to do it, so they go ahead.  Client is very relaxed and engaged in listening the whole session. He smiles a lot. His eyes look right into therapist’s eyes. He is obviously happy, and he has a strong sense of accomplishment as he is proud of himself for doing the experiment.

CONCLUSIONS AND SUMMARY OF CHANGES: Client is much more engaged; no outbursts after Day 2.  Even in Day 1 and 2, the outbursts were just slight – like he is tired, does not want to this anymore today, etc. Client’s face, especially his eyes, has more activation, life force in that area.  

1 week later observations: A video of client is recorded with him talking about the differences he has felt. He seems to be aware that he is not as angry, a little happier.  

In video he talks of his ears being “stopped up”. Therapist finds this interesting and asks him to explain more.  From talking with him, some on video, some later, he seems to feel like his hearing gets like it does when there are pressure differences (like when flying).  He describes this as his ears being stopped up—he is actually meaning that they have cleared and are equal pressured and he is hearing better. He says it a little opposite sometimes but that seems to be because it is complicated for a four year old to explain.  He is equating the holding the nose and blowing to clear the ears as being stopped up.

Also enclosed is a video of his sister talking of client’s change.  She has seen a change. Her main points are the he has not had as many temper tantrums, and seems to be listening better.


Mother reports less anger, that he listens a bit more, and seems to be more engaged with her and sister.  


Pictures taken before the intervention:

Pictures taken after the intervention:

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